A 75-year-old man comes to the office for evaluation of right hip pain. The patient first noticed the pain several months ago and it has become increasingly worse. He now has trouble putting on his shoes and socks. The patient used to walk his dog for 2 miles each night, but he now must use a cane and can only walk a half-mile. The patient has a history of hypertension. BMI is 32 kg/m². X-ray of the right hip is shown below: Which of the following is the most likely cause of this patient's hip pain?

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11ec25c8_d826_53fb_bc81_c1657fb7fb7f_MD0003_00 This patient has chronic joint pain that is worse with activity and weight bearing. The x-ray shows loss of the normal joint space, periarticular osteophytes, and sclerosis of the acetabular surface. Together, these are typical findings of osteoarthritis of the hip. Osteoarthritis is characterized by progressive destruction of the articular cartilage. The pain of hip osteoarthritis is typically felt in the groin, buttock, or lateral hip region, and can radiate to the lower thigh. Patients may have mild pain and brief stiffness with prolonged rest, but the worst pain usually occurs with activity and weight bearing. Examination findings often include decreased rotational range of motion with no synovitis (redness, warmth). (Choice A) Avascular necrosis (osteonecrosis) is characterized by reduced perfusion of the femoral head and collapse of the periarticular bone and can present with hip pain and reduced range of motion. Most atraumatic cases are associated with glucocorticoid or alcohol use. X-ray findings include subchondral lucency and loss of the normal spherical contour of the femoral head, but the joint space is preserved and osteophytes are not present. (Choice B) Fracture of the femoral neck is most common in elderly patients following an acute fall. Examination typically shows a shortened and externally rotated leg, with severe pain on range of motion. X-ray reveals shortening and angulation of the femoral neck. shortening and angulation (Choice C) Greater trochanteric pain syndrome (formerly trochanteric bursitis) is caused by friction of the tendons of the gluteus medius and tensor fascia lata over the greater trochanter of the femur. Pain is localized to the lateral hip and is worsened by direct pressure. X-ray is typically normal. (Choice D) Dislocation of the hip is uncommon in adults and is typically seen only in the context of major trauma. X-ray would show displacement of the femoral head from the acetabulum, whereas this patient's femoral head is well centered in the acetabulum. (Choice F) Osteosarcoma is most common in children and adolescents, although it is occasionally seen in adults age >65. The femur is a common location in pediatric patients, but in adults, osteosarcoma more commonly affects the axial skeleton. X-ray shows destruction of trabecular and cortical bone with formation of new periosteal bone. Educational objective: Osteoarthritis of the hip is characterized by chronic pain in the groin, buttock, or lateral hip that is worse with activity and weight bearing. Examination often shows decreased rotational range of motion. X-ray reveals loss of the normal joint space, periarticular osteophytes, and sclerosis of the acetabular surface. References: Radiological aspects of osteoarthritis. (http://www.ncbi.nlm.nih.gov/pubmed/23413010)

A 75-Year-Old Man Comes to the Office for Evaluation of Right